Peritoneal mesothelioma with invasion of the urinary bladder 20 years post radiation therapy for colon adenocarcinoma.

We present the case of a 66-year-old male with a history of iatrogenic bladder injury and radiation therapy for colon adenocarcinoma 20 years prior. A computed tomography of the thorax, abdomen and pelvis, reported a presacral mass with invasion to the bladder, ureters and lymph nodes. An initial bladder biopsy was histologically inconclusive. A later biopsy taken during emergency bypass surgery for small bowel obstruction, while the patient was positive for coronavirus disease of 2019, concluded that the mass was a peritoneal mesothelioma of epithelioid origin. The combination management of cytoreductive surgery with intraperitoneal chemotherapy has been a near universal standard of care for epithelioid peritoneal mesothelioma provided that the patient is an appropriate candidate for surgical interventions. To the best of our knowledge, this is the first case report of malignant peritoneal mesothelioma as a second primary carcinoma, many years after exposure to radiation therapy for colon adenocarcinoma.

Single-stage tubular urethral reconstruction using oral grafts is an alternative to classical staged approach for selected penile urethral strictures.

Penile urethral strictures have been managed by a staged surgical approach. In selected cases, spongiofibrosis can be excised, a neo-urethral plate created using buccal mucosa graft (BMG) and tubularized during the same procedure, performing a "two-in-one" stage approach. We aim to identify stricture factors which indicate suitability for this two-in-one stage approach. We assess surgical outcome and compare with staged reconstruction. We conducted an observational descriptive study. The data were prospectively collected from two-in-one stage and staged penile urethroplasties using BMG in a single center between 2007 and 2017. The minimum follow-up was 6 months. Outcomes were assessed clinically, radiologically, and by flow-rate analysis. Failure was defined as recurrent stricture or any subsequent surgical or endoscopic intervention. Descriptive analysis of stricture characteristics and statistical comparison was made between groups. Of 425 penile urethroplasties, 139 met the inclusion criteria: 59 two-in-one stage and 80 staged. The mean stricture length was 2.8 cm (single stage) and 4.5 cm (staged). Etiology was lichen sclerosus (LS) 52.5% (single stage) and 73.8% hypospadias related (staged). 40.7% of patients had previous failed urethroplasties in the single-stage group and 81.2% in the staged. The most common stricture locations were navicular fossa (39.0%) and distal penile urethra (59.3%) in the single-stage group and mid or proximal penile urethra (58.7%) in the staged group. Success rates were 89.8% (single stage) and 81.3% (staged). A trend toward a single-stage approach for select penile urethral strictures was noted. We conclude that a single-stage substitution penile urethroplasty using BMG as a "two-in-one" approach is associated with excellent functional outcomes. The most suitable strictures for this approach are distal, primary, and LS-related strictures.

Syringoceles of Cowper's ducts and glands in adult men.

Cowper's syringoceles are uncommon, usually described in children and most commonly limited to the ducts. We describe more complex variants in an adult population affecting with varying degrees of severity, the glands themselves, and the complications they may lead to. One hundred consecutive urethrograms of patients with unreconstructed strictures were reviewed. Twenty-six patients (mean age: 41.1 years) with Cowper's syringoceles who were managed between 2009 and 2016 were subsequently evaluated. Presentation, radiological appearance, treatment (when indicated), and outcomes were assessed. Of 100 urethrograms in patients with strictures, 33.0% demonstrated filling of Cowper's ducts or glands, occurring predominantly in patients with bulbar strictures. Only 1 of 26 patients with non-bulbar strictures had a visible duct/gland. Of 26 symptomatic patients, 15 presented with poor flow. In four patients, a grossly dilated Cowper's duct obstructed the urethra. In the remaining 11 patients, a bulbar stricture caused the symptoms and the syringocele was identified incidentally. Eight patients presented with perineal pain. In six of them, fluoroscopy and magnetic resonance imaging (MRI) revealed complex multicystic lesions within the bulbourethral glands. Four patients developed perineoscrotal abscesses. In the 11 patients with strictures, the syringocele was no longer visible after urethroplasty. In three of four patients with urethral obstruction secondary to a dilated Cowper's duct, this resolved after transperineal excision (n = 2) and endoscopic deroofing (n = 1). Five of six patients with complex syringoceles involving Cowper's glands were excised surgically with symptomatic relief in all. In conclusion, Cowper's syringocele in adults is more common than previously thought and may cause lower urinary tract symptoms or be associated with serious complications which usually require surgical treatment.

Enterovesical Fistula Secondary to Transitional Cell Carcinoma of the Bladder.

Although fistulae between the urinary bladder and the gastrointestinal tract are not uncommon, those caused by carcinoma of the urinary bladder are rare. This report describes the case of an 85 years old male who was diagnosed with a mass involving the small bowel and the urinary bladder during the course of investigation for recurrent urinary tract infections. At laparotomy, the presence of an enterovesical fistula involving the ileum and bladder was confirmed. Histopathological examination of the resected mass showed poorly differentiated urothelial carcinoma. No early postoperative complications were encountered and postoperative cystography showed healing of the bladder without evidence of leakage. Due to the patient's age and comorbidities, no further oncological treatment was offered. Three months later the patient was readmitted to hospital with a severe pneumonia to which he succumbed.

The Nontransecting Approach to Bulbar Urethroplasty.

The standard treatment of bulbar urethral strictures of appropriate length is excision and primary anastomosis (EPA), irrespective of the cause of the stricture. This involves transection of the corpus spongiosum (CS) and disruption of the blood flow within the CS as a consequence. The success rate of EPA in curing these strictures is very high, but there is a considerable body of evidence and of opinion to suggest that there is a significant risk of sexual dysfunction and, potentially, of other adverse consequences that occur because of transection of the CS.

Urethral atrophy after implantation of an artificial urinary sphincter: fact or fiction?

OBJECTIVES: To investigate the concept of 'urethral atrophy', which is often cited as a cause of recurrent incontinence after initially successful implantation of an artificial urinary sphincter (AUS); and to investigate the specific cause of the malfunction of the AUS in these patients and address their management. PATIENTS AND METHODS: Between January 2006 and May 2013, 50 consecutive patients (mean age 54.3 years) with recurrent incontinence had their AUS explored for malfunction and replaced with a new device with components of exactly the same size, unless there was a particular reason to use something different. Average time to replacement of the device was 10.1 years. The mean follow-up after replacement of the device was 24.7 months. All patients without an obvious cause for their recurrent incontinence had preoperative urodynamic evaluation, including measurement of the Valsalva leak point pressure (VLPP) and the retrograde cuff occlusion pressure (RCOP). After explantation of the AUS in patients without any apparent abnormality of the device at the time of replacement, the pressure generated by the explanted pressure-regulating balloon (PRB) was measured manometrically, when this was possible. In a select group of six consecutive patients of this type, the fibrous capsule surrounding the old cuff was incised then excised to expose and evaluate the underlying corpus spongiosum. RESULTS: In 31 of the 50 patients (62%) undergoing exploration, a specific cause for the malfunction of their AUS was defined. In the other 19 patients (38%) no cause was found, either preoperatively or at the time of exploration, other than a low VLPP and RCOP. A typical 'waisted' or 'hour-glass' appearance of the underlying corpus spongiosum was demonstrable, to some degree, on explanting the cuff in all cases. In the six patients in whom the restrictive sheath surrounding the cuff was excised, the urethral circumference immediately returned to normal after the compressive effect of the sheath was released. Manometry of the explanted PRBs, when this was possible, showed a loss of pressure in all instances. Replacement of the explanted AUS with a new device with the same size cuff and PRB in 14 of these 19 patients was successful in 12 (85.7%). CONCLUSIONS: These results, and other theoretical considerations, suggest that recurrent incontinence, years after initially successful implantation of an AUS, is because of material failure of the PRB, probably attributable to its age and consequent loss of its ability to generate the pressure it was designed to produce, and that urethral atrophy does not occur. Simply replacing the old device with a new one with the same characteristics, unless there is a particular reason to do otherwise, is usually successful and avoids the complications of alternatives such as as cuff downsizing, implanting a PRB with a higher pressure range, implantation of a second cuff or transcorporeal cuff placement, all of which have been advocated in these patients.

Fistulation into the Pubic Symphysis after Treatment of Prostate Cancer: An Important and Surgically Correctable Complication.

PURPOSE: Chronic pubic pain after the treatment of prostate cancer is often attributed to osteitis pubis. We have become aware of another complication, namely fistulation into the pubic symphysis, which is more serious and more common than previously thought. MATERIALS AND METHODS: A total of 16 patients were treated for urosymphyseal fistulas after the treatment of prostate cancer between January 2011 and April 2014. Clinical presentation was characterized by chronic, debilitating pubic/pelvic/groin pain in all patients. Diagnosis was confirmed by magnetic resonance imaging. Conservative management was successful in only 1 patient. The remaining patients were treated surgically with excision of the fistulous track and involved symphyseal bone and omentoplasty, followed by reconstruction when feasible. RESULTS: All 16 patients had had radiotherapy as primary treatment (8) or after prostatectomy (8). There were 5 patients (31.3%) who underwent various combinations of brachytherapy, external beam radiotherapy and cryotherapy. Bladder neck contractures developed in 13 patients (81.3%), whose treatment (endoscopic or open reconstruction) resulted in urinary leak leading to urosymphyseal fistulas. Reconstruction was possible in 7 of 15 patients (46.7%) with salvage radical prostatectomy and substitution/augmentation cystoplasty. The other 8 patients (53.3%) underwent cystectomy and ileal conduit diversion. All patients experienced resolution of symptoms, most significantly the almost immediate resolution of pain. CONCLUSIONS: A high index of suspicion must be maintained in irradiated patients presenting with symptoms suggestive of urosymphyseal fistulas, especially after having undergone treatment of bladder neck contractures or prostatic urethral stenoses. Although extensive, surgery for urosymphyseal fistulas, with a high risk of morbidity and mortality and a protracted recovery, leads to immediate and dramatic improvement in symptoms.

Non-transecting bulbar urethroplasty.

Excision and end-to-end anastomosis (EPA) has been the preferred urethroplasty technique for short bulbar strictures and is associated with an excellent functional outcome. Driven by concerns over the potential morbidity associated with dividing the urethra, therefore compromising spongiosal blood flow, as well as spongiofibrosis being superficial in the majority of non-traumatic bulbar strictures, the non-transecting technique for bulbar urethroplasty has been developed with the aim of achieving the same success as EPA without the morbidity associated with transection. This manuscript highlights the fundamental principles underlying the ongoing debate-transection or non-transection of the strictured bulbar urethra? The potential advantages of avoiding dividing the corpus spongiosum of the urethra are discussed. The non-transecting anastomotic procedure together with its various modifications are decribed in detail. Our experience with this technique is presented. Non-transecting excision of spongiofibrosis with preservation of well vascularised underlying spongiosum provides an excellent alternative to dividing the urethra during urethroplasty for short non-traumatic proximal bulbar strictures.

Surgical correction of bladder neck contracture following prostate cancer treatment.

The surgical and non-surgical treatment of localised prostate cancer may be complicated by bladder neck contractures, prostatic urethral stenoses and bulbomembranous urethral strictures. In general, such complications following radical prostatectomy are less extensive, easier to treat and associated with a better outcome and more rapid recovery than the same complications following radiotherapy, high-intensity focussed ultrasound and cryotherapy. Treatment options range from minimally invasive endoscopic procedures to more complex and specialised open surgical reconstruction.In this chapter the surgical management of bladder neck contractures following the treatment of prostate cancer is described together with the management of prostatic urethral stenoses and bulbomembranous urethral strictures, given the difficulty in distinguishing them from one another clinically.

Reparación quirúrgica de la esclerosis de cuello vesical despues del tratamiento del cáncer de prostata / Surgical correction of bladder neck contracture following prostate cancer treatment

Los tratamientos del cáncer de próstata, quirúrgicos y no quirúrgicos, se pueden complicar con esclerosis del cuello vesical, estenosis de la uretra prostática y estenosis de la uretra bulbomembranosa. En general, dichas complicaciones son menos extensas después de la prostatectomía radical, más fáciles de tratar y asociadas con mejores resultados y recuperaciones más rápidas que las mismas complicaciones cuando aparecen después de radioterapia, HIFU y crioterapia. Las opciones de tratamiento van desde procedimientos endoscópicos mínimamente invasivos hasta reconstrucciones quirúrgicas abiertas mas complejas y especializadas. En este capítulo se describe el manejo quirúrgico de las esclerosis de cuello vesical después del tratamiento del cáncer de próstata junto con el manejo de las estenosis uretroprostáticas y de uretra bulbomembranosa, dada la dificultad en distinguir una de otra clínicamente

The surgical and non-surgical treatment of localised prostate cancer may be complicated by bladder neck contractures, prostatic urethral stenoses and bulbomembranous urethral strictures. In general, such complications following radical prostatectomy are less extensive, easier to treat and associated with a better outcome and more rapid recovery than the same complications following radiotherapy, high-intensity focussed ultrasound and cryotherapy. Treatment options range from minimally invasive endoscopic procedures to more complex and specialised open surgical reconstruction. In this chapter the surgical management of bladder neck contractures following the treatment of prostate cancer is described together with the management of prostatic urethral stenoses and bulbomembranous urethral strictures, given the difficulty in distinguishing them from one another clinically

Use of a modified syringe barrel to ensure control of the Amplatz sheath during percutaneous nephrolithotripsy in obese patients.

Percutaneous nephrolithotripsy (PNL) has been shown to be safe and effective in obese patients. One technical problem specifically encountered in these patients is migration of the Amplatz sheath beneath the skin or muscle fascia. We describe a simple technique, making use of a modified 10-cc syringe barrel, to facilitate retrieval of a migrated access sheath in obese patients undergoing percutaneous nephrolithotripsy. This can also be adopted to prevent loss of the working sheath in the first place, as well as to provide some extra length to access the collecting system avoiding the need to convert to longer instrumentation. This technique is cheap, safe, and effective. It avoids the need to extend the skin incision, resulting in improved cosmesis and reduced postoperative pain.